Return to play after shoulder injury and high performance training in the overhead athlete
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1 Return to play after shoulder injury and high performance training in the overhead athlete Dr Ann Cools, PT, PhD Dept Rehab. Sciences & Physiotherapy Ghent University, Belgium Shoulder and scapular measurements 1. Why? 2. What? 3. How? 4. Criteria for injury prevention and RTP? 1
2 WHY?? Injury Prevention in overhead athletes: sportspecific adaptations in ROM, strength and scapular position known to be risk factors for shoulder injuries (Byram et al. AJSM 2010, Shanley et al. AJSM 2012, Kawasaki et al. JSES 2012, Clarsen et al. BJSM 2014) Return to play criteria after shoulder injury should be based on objective measurements according to the Decision Based RTP model (Matheson et al. CJSM 2011) 2
3 Ideal criteria for return to play McCarty et al. Clin Sports Med 23 (2004) Little/no pain Patient subjectivity Near normal ROM Near normal strength Normal functional ability Normal sport-specific skills What should we measure? Outcome measurements and return to play decision: 1. GLENOHUMERAL JOINT (Cools JSES 2014, Johansson JAT 2014) 1. GH IR and ER ROM 2. GH rotator cuff strength 3. Eccentric strength of the external rotators 2. SCAPULOTHORACIC JOINT (Cools BJSM 2010) 1. Scapular upward rotation 2. Strength of the Scapular stabilizers 3. PM Length / PM Index 3
4 PRACTICE 1. ROM IR-ER 2. Strength IR-ER 1. Ecc ER strength For each of the measurements: Arguments for methodology? Reliability (ICC, SEM, MDC)? Cut off values / normal values? 4
5 1. ROM MEASUREMENT Using a goniometer (Wilk AJSM 2011) Using an inclinometer (Wilk AJSM 2011) Using a smartphone (Shin Man Ther 2012) Reliability? Excellent inter- and intra- tester reliability (ICC= 0.98, SEM=+/- 2, MDC= +/- 4 ) (Cools et al. JSES 2014) Frontal or scapular plane / scapular fixation (Wilk et al. AJSM 2011, Cools et al. JAT 2014) 5
6 Cut-off values for prevention and RTP? < side difference for IR < 5-10 side difference for total ROM (ER + IR) ROM measurements: sportspecific adaptations A loss of >25 into IR is predictive for injury in baseball players. (Shanley et al. AJSM 2012) 6
7 ROM measurements: sportspecific adaptations A loss of 18 IR and a loss of 5 in TROM increases the risk for injury x2. (Wilk et al. AJSM 2011, Clarsen BJSM 2014) Results from this procedure in overhead athletes (Cools et al. JAT 2014) 7
8 2. STRENGTH MEASUREMENT Manual Muscle Testing Isokinetic strength testing Isometric testing with HHD Reliability? Excellent inter- and intra- tester reliability for isometric testing: (ICC= , SEM= 4-7N, MDC= 10-16N) (Cools et al. JSES 2014) 8
9 Cut-off values for prevention and RTP? Isokinetic testing: ER/IR ratio > 65% Isometric HHD: 0-0: ER/IR ratio 75% 90-0: ER/IR ratio % (depending on gender) 90-90: ER/IR 60-85% (depending on gender) (Cools et al. KSSTA 2015) Results from this procedure on overhead athletes (Cools et al. JAT 2014) 9
10 3. Eccentric testing of the rotator cuff with a HHD (Johansson JAT 2015) Reliability and validity? (Johansson JAT 2015) MDC90 (Minimal Detectable Change) = 20-30N clinician can be 90% sure that the real score is within the measured score +/- MDC Within tester reliability tester 1 Tester 2 Trial 1 127,2N 119,1N Trial 2 122,0N 112,2N Trial 3 110,9N 111,5N ICC between trials
11 Reliability and validity? (Johansson JAT 2015) Between tester reliability Tester 1 120,1N Tester 2 114,2N ICC between testers 0,71 Validity with Biodex CompuFET 114,2N Biodex 110,9N Pearson Correlation coefficient 0,78 Cut-off values for prevention and RTP? Dominant side + 10% Ecc ER (normalized N/kg): 2-2,5 (depending on sports and age) Ecc ER/isom IR: 0,97-1,3 (depending on gender) (Cools et al. KSSTA 2015) 11
12 Functional testing? Seated Medicine Ball Throw (Van den Tillaer JSCR 2013) Functional testing? Seated Medicine Ball Throw Moderate to high correlation (> 0.75) between SMBT and muscle strength RC and elbow flexors/extensors (Borms accepted JAT 2015) 12
13 Functional testing? Y-balance test (Westrick et al. IJSM 2012) Functional testing? Y-balance test NO significant correlation between Y-balance test and muscle strength RC and scapular protraction and retraction (Borms accepted JAT 2015) 13
14 Take home messages use reliable assessment tools for risk factor analysis and return-to-play decision Challenge sportspecific demands? Return to play exercises for 1/ gymnast 2/ preparing the athlete for impact (goal keepers, hockey ) 14
15 High performance exercises for the gymnast Len Vande Lanotte Flemish Gymnastic Federation High performance exercises for the gymnast Len Vande Lanotte Flemish Gymnastic Federation 15
16 High performance exercises for the gymnast Len Vande Lanotte Flemish Gymnastic Federation High performance exercises for the gymnast Len Vande Lanotte Flemish Gymnastic Federation 16
17 13 weeks 6x/w Open versus Sling exercises Sling exercises are equally as effective as open chain exercises in a strength training program for women, with a small advantage for sling regarding push-up Value of sling therapy (K. De Mey et al. J Strength Cond Res 2013) 17
18 (K. De Mey et al. J Strength Cond Res 2013) With with Conclusion of the study: The large glenohumeral muscles were highly activated when using RS, especially the pectoralis major during the push-up and knee prone bridging exercise and the posterior deltoid and latissimus dorsi during the pull-up exercise. (K. De Mey et al. J Strength Cond Res 2013) 18
19 No consensus in literature Overall increased activity in scap muscles and PM in slings (Lee J Phys ther Sci 2013) More SA activity in ER position (Lee J Phys ther Sci 2013) More triceps activity and upper trap in slings (Borreani Phys Ther Sport 2015) Preparing the athlete for HIGH LEVEL IMPACT 19
20 Preparing the athlete for HIGH LEVEL IMPACT Preparing the athlete for HIGH LEVEL IMPACT 20
21 Preparing the athlete for HIGH LEVEL IMPACT Preparing the athlete for HIGH LEVEL IMPACT 21
22 practice 22
24/01/2015. Return to play after shoulder injury and high performance training in the overhead athlete. Shoulder and scapular measurements:
Return to play after shoulder injury and high performance training in the overhead athlete Dr Ann Cools, PT, PhD Dept Rehab. Sciences & Physiotherapy Ann Cools return Ghent to play and University, high
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